2.0 Analysis 2.1 General Based on a review of the aircraft's maintenance logs and on an examination of other available data, it is considered unlikely that this accident was caused by a mechanical malfunction. This conclusion is supported by radar information regarding aircraft speed, heading, and altitude and by physical evidence at the impact site. Although the Board recognizes a possibility that some unknown mechanical problem or increased workload may have distracted the crew before impact, the essential safety issue remains that the flight was being conducted at night, under VFR, and well below the minimum obstacle clearance prescribed by the CARs. In part, these obstacle clearance requirements, in conjunction with minimum weather requirements, are in place to mitigate the inherent risks associated with night VFR flight. Operations below these minima increase the risks associated with the flight. This analysis will concentrate on how a night VFR operation, conducted below minimum obstacle clearance altitudes, may have started and, more significantly, how it could have continued despite a number of monitoring safeguards (defences) designed into the commercial aviation system. 2.2 VFR Operation The accident flight was typical of previous flights conducted by the crew members. Their consistent practice was to cancel their IFR flight plan and proceed under visual flight rules that applied to day, rather than night, operations. Although the reason for this practice is unknown, it is likely that crews perceived some form of time, cost, or efficiency advantage from selecting VFR, rather than IFR, flight. 2.3 Obstacle Clearance The CARs require that night VFR commercial operations be conducted above a minimum obstacle clearance altitude as a defence against CFIT accidents. The obstacle clearance rules are independent of the VFR weather limits. When properly applied, this regulation restricts the opportunity for a pilot to choose VFR operations over IFR operations in reduced weather conditions. It is possible that the crew members involved, like others in the aviation industry, were not aware of the night VFR obstacle clearance regulation. This lack of awareness would not be unique: two previous TSB investigations (TSB Report Nos. A97C0215 and A98P0303) identified similar deficiencies in other companies' COMs, as well as a lack of awareness by other companies and their flight crews of the night VFR obstacle clearance requirements for controlled airspace. 2.4 Weather The crew received their pre-flight weather package at 0530. Based on the information available to them when flight planning, they would have expected the lowest ceiling at Victoria to be temporarily 2000 feet agl. The Victoria ATIS changed three times in one-half hour because of changing weather conditions. The crew routinely would obtain Victoria ATIS either on the ground in Vancouver or just after take-off. If that procedure was followed on the day of the accident, the crew would have received ATIS information Bravo. That recording indicated a ceiling of 1000 feet at Victoria. A subsequent special observation indicating an 800-foot ceiling was likely not received by the crew because it was transmitted on ATIS information Charlie, commencing at 0627, about six minutes before the crash. Based on this timing, it is unlikely that the crew was aware of the presence of an undercast layer at 800 feet. The lowest ceiling likely expected would have been 1000 feet. This assessment is consistent with radar information that shows the aircraft descending to a level flight altitude of 900 feet, slightly lower than the anticipated cloud base. The ceiling over Mayne Island at the time of the accident was reportedly about 800 feet asl. The initial impact site was above this elevation and, therefore, above the probable cloud base. It is probable that the aircraft inadvertently entered or flew above the low cloud ceiling before striking the trees on Mayne Island. Radar and crash site data show that the aircraft was in level flight at impact. Therefore, it is likely that the crew hit the trees on Mayne Island without any warning of the collision. 2.5 Flight Monitoring Crews involved in this operation routinely cancelled their centre-stored IFR flight plans and proceeded under VFR. The company's operations certificate allowed the operation to be conducted under day and night VFR, as well as under IFR. Until this accident occurred, Kelowna Flightcraft had no internal direction to restrict VFR flight. Despite a range of safeguards governing commercial operations, neither the company flight followers, the chief pilot, the director of flight operations, nor the TC inspectors involved were aware that the DC-3 operation was being conducted consistently under VFR and without regard for, or knowledge of, the obstacle clearance requirements outlined in the CARs. 2.6 Equipment A GPWS could have warned the crew of an impending collision with terrain, but this aircraft was not so equipped. Although such equipment is required on larger passenger-carrying jet aircraft, the requirement does not extend to dedicated cargo aircraft or to propeller-driven aircraft operating under Part VII of the CARs. GPWS equipment is a recognized defence against CFIT accidents and could be used to enhance safety in other high-risk operational environments. Had this type of equipment been installed on the accident aircraft, the likelihood of this accident occurring would have been reduced. 2.7 Dangerous Goods The aircraft was carrying a small amount of dangerous goods. These items were packaged in accordance with governing directives, were listed on the manifest, and were known to be present by the crew of the aircraft and by others in the transportation system. However, air traffic control, search and rescue personnel from the Department of National Defence, and other first responders were not aware of the presence of the dangerous goods. This lack of knowledge placed the first responders at increased risk after the crash. 3.0 Conclusions 3.1 Findings as to Causes and Contributing Factors The accident flight was not conducted in accordance with the night obstacle clearance requirements of Canadian Aviation Regulation (CAR) 705.32. The Kelowna Flightcraft company operations manual did not reflect the restrictive conditions imposed on night visual flight rules (VFR) flight by CAR 705.32. Such information might have prevented the accident by ensuring the crew's awareness of those night obstacle clearance standards. As the aircraft approached Mayne Island, it encountered a low cloud ceiling that was based about 800 feet and that reduced visual reference with the surface. When the aircraft struck trees, it was being flown in controlled, level flight at an altitude below the surrounding terrain. The aircraft was not equipped with a ground proximity warning system or any other similar system that could warn the crew of an impending collision with terrain. Such systems were not required by regulation. 3.2 Findings as to Risk Kelowna Flightcraft flight operations personnel were not aware that most of the DC-3 flights were being conducted under VFR. First responders were not aware of the presence of the dangerous goods and were therefore at increased risk during their response activities on the site. 3.3 Other Findings Transport Canada officials responsible for monitoring this operation were not aware that most of the DC-3 flights were being conducted under VFR at night and below the required obstacle clearance altitudes. 4.0 Safety Action 4.1 Action Taken The Kelowna Flightcraft company operations manual was amended on 14 January 1999 to reflect the restrictive conditions imposed on night visual flight rules (VFR) flight by CAR 705.32. Kelowna Flightcraft issued a memorandum to all its pilots on 15 January 1999 to highlight the minimum obstacle clearance regulations related to Canadian Aviation Regulations (CARs) Part VII operators. The memorandum additionally stated that, until further notice, night VFR flights are not authorized without the consent of the director of flight operations or the company chief pilot. Kelowna Flightcraft installed an Internet-based flight monitoring system into its system operations control. This system, called Flight Explorer, allows for real-time monitoring of company aircraft while in flight and displays a number of operational parameters, including, in part, aircraft type, departure time, route of flight, altitude, and estimated time of arrival. Transport Canada (TC) issued Commercial and Business Aviation Advisory Circular (CBAAC) number 0153, dated 12 March 1999, reiterating the CARs requirements for night VFR operations and providing advance notice that the generic operations manual would be amended on the next cycle to include all relevant regulations related to night VFR flight by commercial operators. TC issued CBAAC number 0161, dated 31 August 1999, detailing a new requirement for all CARs Section 703 (Air Taxi), 704 (Commuter), and 705 (Airline) operators to undergo mandatory training for the avoidance of controlled flight into terrain (CFIT) accidents. TC raised two notices of proposed amendments to the CARs aimed at restricting night VFR operations for Section 704 and 705 operators. These notices of proposed amendments are currently being processed through the Canadian Aviation Regulation Advisory Council. The British Columbia Chief Coroner held an inquest into the deaths of the two pilots. Recommendations from the coroner have been forwarded to the Minister of Transport for consideration, and all have received a positive response. One recommendation was that Transport Canada pursue the requirements of installing ground proximity warning systems (GPWS) in all aircraft operating under CARs 703, 704, and 705. In his response to that recommendation, the Minister of Transport explained the current regulations regarding GPWS and stated that TC is committed to harmonizing its regulations, as much as possible, with the US Federal Aviation Administration's terrain avoidance warning system final rule.